The Educationally Handicapped Child—The Physician's Place in a Program to Overcome Learning Disability

Under California Assembly Bill 464, special classes may be provided by school districts for children designated as educationally handicapped. An educationally handicapped child is not mentally retarded or physically disabled. He may have neurological handicap or emotional disorder, but he must show impaired achievement in relation to his tested abilities.A physician may be asked to participate in the program, either as a specified member of the admissions committee of the school district or to provide a medical clearance for entrance of one of his own patients into the program.He does a thorough history and physical examination but adds special examination of attention, activity, coordination and attitudes.The educationally handicapped child is helped most by the physician who does not reject the idea of educational handicap even if the medical examination is negative; who treats his minor ills; who medicates, when it is indicated, for hyperactivity, distractibility or extreme anxiety; who cooperates with parents and school personnel.     

The Physician and Workmen's Compensation—A New Paramedic to Help with Compensation Cases

The first social, no-fault, insurance legislation in California was the Workmen''s Compensation Act of 1911. It has been changed and modified in the years since, and is having an increasing impact on the practice of most California physicians. Many physicians consider caring for the occupationally ill or injured time-consuming and difficult. A newly emerging kind of paramedic, the workmen''s compensation benefit administrator, is available to assist the physician in overcoming difficulties encountered. A cooperative effort between the physician and the benefit administrator will expedite management of industrial patients.     

Can Score Databanks Help Teaching?

Background

Basic courses in most medical schools assess students'' performance by conferring scores. The objective of this work is to use a large score databank for the early identification of students with low performance and to identify course trends based on the mean of students'' grades.

Methodology/Principal Findings

We studied scores from 2,398 medical students registered in courses over a period of 10 years. Students in the first semester were grouped into those whose ratings remained in the lower quartile in two or more courses (low-performance) and students who had up to one course in the lower quartile (high-performance). ROC curves were built, aimed at the identification of a cut-off average score in the first semesters that would be able to predict low performances in future semesters. Moreover, to follow the long-term pattern of each course, the mean of all scores conferred in a semester was compared to the overall course mean obtained by averaging 10 years of data. Individuals in the low-performance group had a higher risk of being in the lower quartile of at least one course in the second semester (relative risk 3.907; 95% CI: 3.378–4.519) and in the eighth semester (relative risk 2.873; 95% CI: 2.495–3.308). The prediction analysis revealed that an average score of 7.188 in the first semester could identify students that presented scores below the lower quartiles in both the second and eighth semesters (p<0.0001 for both AUC). When scores conferred by single courses were compared over time, three time-trend patterns emerged: low variation, upward trend and erratic pattern.

Conclusion/Significance

An early identification of students with low performance may be useful in promoting pedagogical strategies for these individuals. Evaluation of the time trend of scores conferred by courses may help departments monitoring changes in personnel and methodology that may affect a student''s performance.     

Experimenting with Embryos: Can Philosophy Help?

Beyond the well-known ethical issues involved in medical experimentation on human subjects, experimenting with embryos raises unique and particularly hard problems. Beside the psychological obstacles connected with the fear of 'playing God" and the awe with which we hold the process of the creation of human beings, there are three philosophical problems which are the main subject of the article:
1. The logical problem of circularity: the morality of experimenting on embryos is dependent on the status of the embryo, which in turn is partly decided by experimentation.
2. The metaphysical problem: experiments are justified by the benefits they bring to human subjects; but it is doubtful whether an early embryo is a 'subject" and whether coming into being is a 'benefit".
3. The moral problem: the standard constraint on medical experiments is that they benefit either the individual subject or at least members of a relevantly defined group of patients suffering from the same syndrome. But embryo experimentation is often associated with potential cure to people of a completely different category (like geriatric patients).
Finally, the article discusses the limits of the force of philosophical arguments in the formation of actual policies for regulating such practices as experimenting with embryos. The widely-shared fourteen-day limit is shown to be a sound practical compromise despite the difficulties in justifying it philosophically.     

The Benefits of Photorespiratory Bypasses: How Can They Work?

Bypassing the photorespiratory pathway is regarded as a way to increase carbon assimilation and, correspondingly, biomass production in C₃ crops. Here, the benefits of three published photorespiratory bypass strategies are systemically explored using a systems-modeling approach. Our analysis shows that full decarboxylation of glycolate during photorespiration would decrease photosynthesis, because a large amount of the released CO₂ escapes back to the atmosphere. Furthermore, we show that photosynthesis can be enhanced by lowering the energy demands of photorespiration and by relocating photorespiratory CO₂ release into the chloroplasts. The conductance of the chloroplast membranes to CO₂ is a key feature determining the benefit of the relocation of photorespiratory CO₂ release. Although our results indicate that the benefit of photorespiratory bypasses can be improved by increasing sedoheptulose bisphosphatase activity and/or increasing the flux through the bypass, the effectiveness of such approaches depends on the complex regulation between photorespiration and other metabolic pathways.In C₃ plants, the first step of photosynthesis is the fixation of CO₂ by ribulose bisphosphate (RuBP). For every molecule of CO₂ fixed, this reaction produces two molecules of a three-carbon acid, i.e., 3-phosphoglycerate (PGA), and is catalyzed by the Rubisco enzyme. A small portion of the carbon in PGA is used for the production of Suc and starch, whereas the remainder (i.e. five-sixths) is used for the regeneration of RuBP (Fig. 1). The regeneration of the Rubisco substrate RuBP in the Calvin-Benson-Bassham (CBB) cycle ensures that ample RuBP is available for carbon fixation (Bassham, 1964; Wood, 1966; Beck and Hopf, 1982). Rubisco is a bifunctional enzyme that catalyzes not only RuBP carboxylation but also RuBP oxygenation (Spreitzer and Salvucci, 2002). RuBP oxygenation generates only one molecule of PGA and one molecule of 2-phosphoglycolate (P-Gly; Ogren, 1984). The photorespiratory pathway converts this P-Gly back to RuBP in order to maintain the CBB cycle.Open in a separate windowFigure 1.Schematic representation of the C3 photosynthesis kinetic model with three different photorespiratory bypass pathways. The bypass described by Kebeish et al. (2007) is indicated in blue, the bypass described by Maier et al. (2012) in pink, and the bypass described by Carvalho et al. (2011) in green. The original photorespiratory pathway is marked in orange, and CO₂ released from photorespiration (including the original pathway and bypass pathways) is indicated in red. 2PGA, 2-Phosphoglyceric acid; ASP, Asp; CIT, citrate; ICIT, isocitrate; PGA, 3-phosphoglycerate; DPGA, glycerate-1,3-bisphosphate; GAP, glyceraldehyde 3-phosphate; DHAP, dihydroxyacetone phosphate; SBP, sedoheptulose-1,7-bisphosphate; S7P, sedoheptulose-7-phosphate; Ri5P, ribose-5-phosphate; Ru5P, ribulose-5-phosphate; FBP, fructose-1,6-bisphosphatase; F6P, fructose 6-phosphate; Xu5P, xylulose-5-phosphate; G6P, glucose-6-phosphate; G1P, glucose-1-phosphate; ADPG, ADP-glucose; F26BP, fructose-2,6-bisphosphate; UDPG, uridine diphosphate glucose; SUCP, sucrose-6F-phosphate; SUC, Suc; PEP, phosphoenolpyruvate; OAA, oxaloacetate; PGCA, phosphoglycolate; GCA, glycolate; GOA, glyoxylate; GCEA, glycerate; MAL, malate; PYR, pyruvate; GLU, glutamate; KG, alfa-ketoglutarate; GLN, Gln; HPR, hydroxypyruvate; RuBP, ribulose bisphosphate; SER, Ser; GLY, Gly; TS, tartronic semialdehyde.In higher plants, P-Gly is dephosphorylated to glycolate, which is transferred into the peroxisomes, where it is oxidized to hydrogen peroxide and glyoxylate. Then, glyoxylate is aminated to produce Gly, which is subsequently transferred to the mitochondria. There, two molecules of Gly are converted into one Ser plus one CO₂ and one NH₃ (Ogren, 1984; Peterhansel et al., 2010). The Ser is ultimately converted back to PGA (Tolbert, 1997). CO₂ and NH₃ are gasses that can escape to the atmosphere (Sharkey, 1988; Kumagai et al., 2011), and the loss of carbon and nitrogen essential for biomass accumulation will decrease the efficiency of photosynthesis and plant growth (Zhu et al., 2010). Fortunately, both substances are partially reassimilated in the chloroplast, but this results in decreased photosynthetic energy efficiency. At 25°C and current atmospheric CO₂ concentrations, approximately 30% of the carbon fixed in C₃ photosynthesis may be lost via photorespiration and the size of this loss increases with temperature (Sharkey, 1988; Zhu et al., 2010). As a result, photorespiration has been regarded as a pathway that could be altered to improve photosynthetic efficiency (Zelitch and Day, 1973; Oliver, 1978; Ogren, 1984; Zhu et al., 2008, 2010).There are several approaches that may be used to alter photorespiration to improve photosynthetic efficiency. First, it might be possible to increase the specificity of Rubisco to CO₂ versus oxygen (S_c/o; Dhingra et al., 2004; Spreitzer et al., 2005; Whitney and Sharwood, 2007). However, previous studies have shown that there is an inverse correlation between S_c/o and the maximum carboxylation rate of Rubisco (Jordan and Ogren, 1983; Zhu et al., 2004), and there are some indications that the S_c/o of different organisms may be close to optimal for their respective environments (Tcherkez et al., 2006; Savir et al., 2010). Second, a CO₂-concentrating mechanism could be engineered into C₃ plants. For example, introducing cyanobacterial bicarbonate transporters (Price et al., 2011) or introducing C₄ metabolism could be used to concentrate CO₂ in the vicinity of Rubisco and, thereby, suppress the oxygenation reaction of Rubisco (Furbank and Hatch, 1987; Mitchell and Sheehy, 2006). Past efforts to introduce a C₄ pathway into C₃ plants have focused on biochemical reactions related to C₄ photosynthesis without taking into account the anatomical differences between C₃ and C₄ plants, which may have been responsible for the limited success of such endeavors (Fukayama et al., 2003). Recently, there has been renewed interest in engineering C₄ photosynthetic pathways into C₃ plants, with efforts focusing on understanding and engineering the genetic regulatory network related to the control of both the anatomical and biochemical properties related to C₄ photosynthesis (Mitchell and Sheehy, 2006; Langdale, 2011).Transgenic approaches have been used to knock down or knock out enzymes in the photorespiratory pathway. Unfortunately, the inhibition of photorespiration by the deletion or down-regulation of enzymes in the photorespiratory pathway resulted in a conditional lethal phenotype (i.e. such plants cannot survive under ambient oxygen and CO₂ concentrations but may be rescued by growing them under low-oxygen or high-CO₂ conditions; for review, see Somerville and Ogren, 1982; Somerville, 2001). Another approach to reduce photorespiration is to block (or inhibit) enzymes in this pathway using chemical inhibitors. Zelitch (1966, 1974, 1979) reported that net photosynthesis increased by inhibiting glycolate oxidase or glycolate synthesis. However, other groups showed that the inhibition of glycolate oxidase or Gly decarboxylation led to the inhibition of photosynthesis (Chollet, 1976; Kumarasinghe et al., 1977; Servaites and Ogren, 1977; Baumann et al., 1981). It turns out that plants cannot efficiently metabolize photorespiratory intermediates without a photorespiratory pathway, and suppression of this pathway inhibits the recycling of carbon back toward RuBP, which is necessary for maintaining the CBB cycle (Peterhansel et al., 2010; Peterhansel and Maurino, 2011). Moreover, the accumulation of toxic metabolic intermediates (e.g. P-Gly) can strongly inhibit photosynthesis (Anderson, 1971; Kelly and Latzko, 1976; Chastain and Ogren, 1989; Campbell and Ogren, 1990). This may explain why earlier attempts to block or reduce photorespiration have failed to improve carbon gain.Instead of reducing photorespiration directly, a promising idea is to engineer a photorespiratory bypass pathway. Such a pathway would metabolize P-Gly produced by RuBP oxygenation but minimize carbon, nitrogen, and energy losses and avoid the accumulation of photorespiratory intermediates. Kebeish et al. (2007) introduced the glycolate catabolic pathway from Escherichia coli into Arabidopsis (Arabidopsis thaliana); we will subsequently call this type of bypass the Kebeish bypass. In such transgenic plants, glycolate is converted to glycerate in the chloroplasts without ammonia release (Fig. 1). Previous studies suggested that this pathway theoretically requires less energy and shifts CO₂ release from mitochondria to chloroplasts (Peterhansel and Maurino, 2011; Peterhansel et al., 2013); experimental results indicated that the bypass allowed for increased net photosynthesis and biomass production in Arabidopsis (Kebeish et al., 2007). There are reports of two other photorespiratory bypass pathways in the literature (Carvalho, 2005; Carvalho et al., 2011; Maier et al., 2012). In the Carvalho bypass (Carvalho, 2005; Carvalho et al., 2011), glyoxylate is converted to hydroxypyruvate in the peroxisome. Similar to the Kebeish bypass, the ammonia release is abolished, one-quarter of the carbon from glycolate is released as CO₂ in the peroxisomes, and three-quarters of the carbon from glycolate is converted back to PGA. However, this pathway has only been partially realized in tobacco (Nicotiana tabacum); that is, the enzyme of the second reaction of this pathway was not detectable in the transgenic plants, and plants expressing this pathway showed stunted growth when grown in ambient air (Carvalho et al., 2011). The Maier bypass (Maier et al., 2012) is characterized by complete oxidation of glycolate in the chloroplasts. Initial results suggested that the photosynthesis and biomass of transgenic Arabidopsis with this pathway were enhanced (Maier et al., 2012).Recently, the design and benefits of the three bypass pathways were reviewed (Peterhansel et al., 2013), and it was suggested that a photorespiratory bypass can contribute to an enhanced photosynthetic CO₂ uptake rate by lowering energy costs and minimizing carbon and nitrogen losses. However, a systematic and quantitative analysis of the potential contributions of these different factors to photosynthesis improvement has not yet been conducted. Systems modeling can help to design new metabolic pathways and improve our understanding of biochemical mechanisms (McNeil et al., 2000; Wendisch, 2005; Zhu et al., 2007; Bar-Even et al., 2010; Basler et al., 2012). Such models have been used successfully to gain insight into the photosynthetic metabolism (Laisk et al., 1989, 2006; Laisk and Edwards, 2000; Zhu et al., 2007, 2013; Wang et al., 2014). In this study, we use an extended kinetic model of C₃ photosynthesis based on earlier work by Zhu et al. (2007) to systematically analyze the potential of three photorespiratory bypass pathways for improving photosynthetic efficiency (Supplemental Model S1). In addition, we determined under what conditions such bypass pathways may lead to increased photosynthesis and biomass production in C₃ plants and how to further improve the photosynthesis of plants with such a bypass. Our analysis suggests that the benefit of a photorespiratory bypass varies dramatically if it is engineered into different crops.     

BRAIN-DAMAGED CHILDREN—The Problem of Relations in the Family Group

Children with minimal brain damage show a characteristic pattern of behavior.Often there are no physical signs of abnormality, but the diagnosis can be made from the history, electroencephalographic tracings, psychologic tests and repeated observations.The behavior is a composite of the effects of the brain damage and the response of the child to his environment. The behavior of the brain-damaged child is frequently so frustrating to parents that attitudes of rejection, withdrawal or excessive punitive measures occur.In the present study, when drugs were given and the child''s behavior improved, the parents were better able to understand the needs of the child and create a better home environment in which there was less frustration and emotional pressure.